Postal Prescription Services Mail Order Form

Transcription

Postage
Required
Post Office will
not deliver
without proper
postage.

Refillstoo soon?
For
medications yyou
need to
to start
start
For maintenance
m aintenance medications
o u need
taking
taking right
right away:
away : you
you may
m ay ask
ask your
your doctor
doctor for
for two
two
prescriptions.
prescriptions. One
One for
fo r a
a small
sm all supply
supply to
to be
be filled
f illed
at
at your
yo ur local
local pharmacy
pharmacy for
fo rimmediate
immediate use,
use, and
and
one
one for
for the
the mail
m ail service
service pharmacy.
pharmacy. Remember
Reme mber
to
to ask
ask the
the doctor
doctor to
to write
write the
the mail
m ail order
order
prescription
fo r the
the maximum
m aximum quantity
quantity your
your plan
plan
prescriptio n for
allows
of refills
refills (if
(if the
the law
law
allow s and
and for
for one
o ne year
year of
allows).
allow s). Then
Then mail
m ail them
th em to
to Postal
Postal Prescription
Prescription
Services
Services following
following these
these easy
easy steps:
steps:
1.
1. On
On the
the front
front of
of each
each new
new prescription,
prescription,
print
print clearly:
cle arly:
•• The
The member’s
member’s name
name and
and relationship
relationship to
to the
the
primary
primary covered
covered person
person
(e.g.,
(e.g., self,
self, spouse,
spouse, child).
child).
•• The
The member’s
member’s ID
ID number
number from
from the
the primary
primary
covered
covered person’s
person’s plan.
plan.
2.
2. Be
Be sure
sure the
the prescribing
prescribing doctor’s
doctor’s
name
name is
is clearly
clearly indicated.
indicated.
3.
the order
3. Complete
Completethe
order form
form
including
including payment
payment information.
information.
4.
Provide aastreet
4.Provide
streetaddress
addressfor
for delivery.
delivery.
Some
Some medications,
medications, such
such as
as narcotics
narcotics
and
and drugs
drugs requiring
requiring refrigeration
refrigeration are
are
restricted
restricted from
from delivery
delivery to
to aa post
post
office
office box.
box.
4. Provide a street address for delivery.
5.
Send
prescriptions,
5.Send
your
prescriptions,
completed
some your
medications,
such completed
as narcotics
order
form,
and
a
co-pay
in
order
form,
and
a
co-pay
in the
the are
and drugs requiring refrigeration
envelope
A
envelope provided.
provided.
A new
new
order
form
restricted
from delivery
to order
a postform
office
and
envelope
will
be
returned
with
and
envelope
will
be
returned
with
box.
each
each Postal
Postal Prescription
Prescription Service
Service
delivery.
delivery.
How to Order
If your doctor has prescribed a
refill, then Postal Prescription
Service will send you a refill slip with your
medication order. When you need the refill,
just detach the refill slip and mail it back with
your completed order form and co-pay.
If you cannot locate your refill slip, list the
prescription numbers and the names of the
medication on the order form. The
prescription number is located in the upper
left-hand corner of the label on your
medication container.
Refills may also be ordered by phone by
calling the toll-free number listed in this
brochure. Please remember to have your
credit card information and the prescription
numbers you would like to order ready. You
can also order refills through our website at
www.ppsrx.com.
Generic Drugs
Generic medications will be substituted for
brand-name medications when available and
allowed by the prescribing physician. PPS
utilizes only those generic medications rated
highest by the FDA.
PPS
PPS PRESCRIPTION SERVICES
PO BOX 2718
PORTLAND OR 97208-2718
IfIf you
you take
take the
the same
same medication
medication for
for
months
months at
at aa time.
time. You’ll
You’ll often
often find
find
that
that getting
getting your
your prescription
prescription
through
through the
the mail
mail will
will be
tie easier
easier and
and
less
getting them
less expensive
expensive than
thangetting
them
from
from your
your local
local pharmacy.
pharmacy.
However,
However, prescription
prescription mail
mail order
order
services
should
not
be
used
services should not be used for
for
medications
medications you
you need
need immediately
immediately
(sooner
(sooner than
than two
two weeks.)
weeks.)
Refer to the reorder date on your refill slip.
For your safety, refill orders placed too early
cannot be filled and may be returned.
Postal Prescription Services
Service & Safety
Postal Prescription Services’
registered Pharmacists review
each prescription for accuracy be
re
fo
dispensing, and perform checks to assure all
prescriptions are dispensed correctly.
We maintain computerized patient profiles to
prevent adverse reactions with other
prescriptions you are receiving from Postal
Prescription Services. Should any questions
arise regarding potential adverse reactions,
our pharmacist will contact your doctor or you,
before dispensing the medication.
Delivery Time
Please allow two weeks for delivery from the
date you mail your order. Your order will be
delivered to the address you requested by United
Parcel Services or first class US mail. In case of
emergency, prescriptions can be shipped overnight
for an additional charge to you. Postal Prescription
Service is open for business Monday through
Friday 6:00 a.m. to 6:00 p.m. and Saturday 9:00 a.m.
to 2:00 p.m., Pacific Time.
To Order Prescriptions
By Mail,
Use the Convenient

Order Form Enclosed.

To Order by Phone:
1-800-552-6694
In Portland, Oregon:
( 503 ) 797-2100
Visit Our Website:
www .ppsrx.com
FROM
Howto Order New
Prescriptions
Questions?
Date I mailed my order
Co-pay Am ount Enclosed $
Tear
Tear here,
here, inser
insertt order
order form
form in
in envelope
envelope and
and seal.
seal.
call: 1-800-552-6694
in Portland, Oregon:
T e a r h e r e , a n d k e e p t h is s t u b f o r y o u r r e c o r d s .
Patient Information
D ru g A lle rg ies / H e a lth C o n d itio n
Primary
Health Care Plan Information
Last Name
Employer Name (if applicable)
Male
Female
First Name
/
/
Date of Birth
M.l.
Female
Male
Doctor/Prescriber name and Phone No.
Dependent
Insured’s Name
If possible, p lease en clo se a
copy o f you r in su ran c e card
w h e n placing yo u r in itia l o rd er
or w h en changing in su ran c e.
Last Name
First Name
/
/
Date of Birth
NONE
CODEINE
ASPIRIN
OTHER
PENICILLIN
Ship To This Address
SULFA
ASTHMA
DIABETES
HIGH BLOOD PRESSURE
HEART DISEASE
HYPERLIPIDEMIA
Last Name
NONE
ASPIRIN
codeine
penicillin
Middle Initial
Street Address
sulfa
OTHER
City
ASTHMA
DIABETES
HIGH BLOOD PRESSURE
HEART DISEASE
HYPERLIPIDEMIA
OTHER
State
Zip Code
Home Phone
Day Phone
NONE
CODEINE
ASPIRIN
OTHER
PENICILLIN
SULFA
M.l.
Male
First Name
OTHER
Spouse
Last Name
Insured’s I.D. Number
M.l.
First Name
/
/
Date of Birth
Health Care Plan
(503) 797-2100
Female
ASTHMA
DIABETES
HIGH BLOOD PRESSURE
HEART DISEASE
HYPERLIPIDEMIA
OTHER
Thank You.
We appreciate your business!
Order prescription refills or transfers here by
enclosing refill slips or filling out this section
Qty. Prescription No.
Nam e of M edication
Strength
Pharm acy Nam e
Pharm acy Phone
Doctor’s N am e & Phone Price or Co-Pay
For new prescriptions, enclose the prescription
in the envelope provided and check here.
Non-Safety Cap Request Information:
Federal law requires that your prescription shall be dispensed in a container with a child resistant or
safety cap unless you request otherwise. If you would like your prescription with an “easy-open” lid

please sign below. I do not want safety caps:
Patient’s Signature Here
Total: $
Method of Payment:
Date
Check
Money Order
Visa/MasterCard
Credit Card Number
Cardholder’s Signature
Discover
Am. Express
Exp. Date
Make check or
money order
payable to: